Signs and Symptoms of Child Abuse and Neglect
Signs and Symptoms of Child Abuse and Neglect ( 8 Questions)
A nurse is providing discharge education to the parents of a 3-year-old client who was physically abused by a babysitter. The nurse instructs the parents to monitor the client for signs of increased intracranial pressure (ICP), as the client had a subdural hematoma that was surgically evacuated. Which of the following signs should the nurse include in the teaching? (Select all that apply.)
Choice A Reason: This is a correct answer. Headache is a sign of increased intracranial pressure (ICP), as the pressure on the brain causes pain and discomfort. Headache may be more difficult to assess in a 3-year-old client, but the nurse should instruct the parents to look for cues such as holding or rubbing the head, crying, or refusing to eat or play.
Choice B Reason: This is a correct answer. Vomiting is a sign of increased intracranial pressure (ICP), as the pressure on the brainstem causes stimulation of the vomiting center and nausea. Vomiting may be more frequent and projectile in a 3-year-old client with increased ICP, and may not be related to food intake or illness.
Choice C Reason: This is a correct answer. Bradycardia is a sign of increased intracranial pressure (ICP), as the pressure on the brainstem causes disruption of the autonomic nervous system and decreased heart rate. Bradycardia may be accompanied by hypertension and irregular respirations, which are known as Cushing's triad, a late and ominous sign of increased ICP.
Choice D Reason: This is not a correct answer. Dilated pupils are not a sign of increased intracranial pressure (ICP), but rather a sign of brain herniation, which is a life-threatening complication of increased ICP. Brain herniation occurs when the brain tissue shifts from its normal position and compresses vital structures such as the cranial nerves and the brainstem. Dilated pupils may indicate compression of the oculomotor nerve (cranial nerve III), which controls pupil constriction.
Choice E Reason: This is a correct answer. Irritability is a sign of increased intracranial pressure (ICP), as the pressure on the brain causes changes in behavior and personality. Irritability may manifest as agitation, restlessness, crying, or aggression in a 3-year-old client with increased ICP, and may not be responsive to soothing or distraction.
Choice A Reason: This is a correct answer. Headache is a sign of increased intracranial pressure (ICP), as the pressure on the brain causes pain and discomfort. Headache may be more difficult to assess in a 3-year-old client, but the nurse should instruct the parents to look for cues such as holding or rubbing the head, crying, or refusing to eat or play.
Choice B Reason: This is a correct answer. Vomiting is a sign of increased intracranial pressure (ICP), as the pressure on the brainstem causes stimulation of the vomiting center and nausea. Vomiting may be more frequent and projectile in a 3-year-old client with increased ICP, and may not be related to food intake or illness.
Choice C Reason: This is a correct answer. Bradycardia is a sign of increased intracranial pressure (ICP), as the pressure on the brainstem causes disruption of the autonomic nervous system and decreased heart rate. Bradycardia may be accompanied by hypertension and irregular respirations, which are known as Cushing's triad, a late and ominous sign of increased ICP.
Choice D Reason: This is not a correct answer. Dilated pupils are not a sign of increased intracranial pressure (ICP), but rather a sign of brain herniation, which is a life-threatening complication of increased ICP. Brain herniation occurs when the brain tissue shifts from its normal position and compresses vital structures such as the cranial nerves and the brainstem. Dilated pupils may indicate compression of the oculomotor nerve (cranial nerve III), which controls pupil constriction.
Choice E Reason: This is a correct answer. Irritability is a sign of increased intracranial pressure (ICP), as the pressure on the brain causes changes in behavior and personality. Irritability may manifest as agitation, restlessness, crying, or aggression in a 3-year-old client with increased ICP, and may not be responsive to soothing or distraction.